ADHD_parent (1)

Adult ADHD Parent Questionnaire
You have been identified as someone who could provide helpful historical and/or current information for this evaluation. Please consider the following questions and answer them to the best of your ability. We appreciate your assistance.
Clients name
Name of person completing form
1 What is your relationship to the individual above
What is your understanding of this disorder?
Observations of client concerning for ADHD?

Now I am doing to ask you about some symptoms. Please indicate whether you observed these symptoms prior to the age of 12 and if you currently observe these symptoms by checking the symptoms observed, leave the box blank if you have not observed the below symptoms. Than note whether you note changes in these items now that the individual is an adult:

	Before age 12	Current	Same	Better?	Worse	Comments Below
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities.
Often has difficulty sustaining attention in tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to failure to understand instructions).
Often has difficulty organizing tasks and activities.
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools).
Is often easily distracted by extraneous stimuli.
Is often forgetful in daily activities.
Often fidgets with hands or feet Or squirms in seat.
Often leaves seat in classroom or in other situations in which remaining seated is expected.
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness.
Often had difficulty playing or engaging feelings of restlessness.
Is often “on the go” or often acts as if “driven by a motor.”
Often talks excessively.
Often blurts out answers before questions have been complete.
Often has difficulty waiting turn.
Often interrupts or intrudes on Others e.g., butts into conversations or games).

Additional Information Regarding ADHD Symptoms:
1. Do you know anyone else in the family who was diagnosed with this disorder?

YesNoNot Sure
2. If yes, how were they treated for this disorder?

Stimulant (Ritalin, Adderall or other form) medication onlyOther medication only (Strattera, Wellbutrin or others)Therapy (group or individual) onlyNot sure how they were treatedOther
3. Did your child see anyone about these problems when he/she was a child or adolescent?

YesNoNot Sure
4. If yes, when and where did they seek treatment?
5. When would you say the problems first began? (Check only one)

0-7 years8-12 years13-15 years16-21 years22 to present
Developmental History:
1. As far as you know, were there any problems with the pregnancy or delivery of

NoYes, explain
As far as you know, did your child walk, talk, and sit up on time?

YesNo, explain
Did your child have any childhood illnesses?

NoYes, explain
4. Did your child ever have seizures?

NoYes, explain
5. Did your child ever have an injury to the head and/or lose consciousness?

NoYes, explain
6. Did your child have encephalitis or an infection in the brain?

NoYes, explain
7. Has your child ever had any tic (made unusual movements or noises) or been diagnosed Tourettes Syndrome.

NoYes, explain
8. Was your child ever diagnosed with a heart problem?

NoYes, explain
9. Was your child ever diagnosed with liver disease?

NoYes, explain
10. Did you think your child was harder to control than children of his or her age as a child?

NoYes, explain
School History
1. Did your child have trouble starting school in kindergarten or first grade?

YesNoNot sure
2. Did your child ever repeat a grade?

NoNot sureYes, which grade(s) did they repeat?
3. Was your child ever in any special classes at school?

NoNot sureYes, please explain what kinds of special classes
4. How would you describe your child’s grades in school?

AverageBetter than averageWorse than average
5. Did teachers think your child did as well as he/she should?

YesNoNot sure
6. Did your child have normal relationships with peers as a child?

YesNoNot sure
7. Was your child ever truant from school?

YesNoNot sure
8. Was your child ever suspended or expelled from school?

YesNoNot sure
9. Did your child ever get into fights at school?

Yes (if yes answer a-d)NoNot sure
Answer questions a-d, only if you answered yes to question 9.
a. During which grades did he/she get into fights? (check all that apply):

PreschoolK to 6th7th to 8thHigh SchoolOther
b. How many times did he/she get into fights?

1 time2 to 5 times6 to 10 timesMore than 10 times
c. Start a fight?

YesNo
d. Use a weapon in a fight?

YesNo
10. Did your child run away from home overnight?

Yes ( answer a&b)No
Answer questions a&b only if you answered yes to question 10.
a. How many times did they run away?

1 time2 to 6 times6 to 10 timesMore than 10 times
b. What was the longest duration they were gone?

1 night2 to 5 nights6 to 10 nightsMore than 10 nights
11. Did your child ever get in trouble for damaging or stealing property?

NoYes, please explain
12. Did your child get in trouble for using alcohol other drugs?

NoYes, please explain
13. Was your child ever arrested or in trouble with the law?

NoYes, please explain
Family History
Is there a family history of? (Check all that apply):

Depression or AnxietyBipolar DisorderHeart problemsHigh blood pressureLegal problemsAlcohol or other drug useSeizure disordersTourette’s or other tic disorderLearning disabilities/school problemsOther medical problems
If there are any additional thoughts or concerns this questionnaire has raised, please feel free to write them down.
Thank you again for your time.

This form is also available in PDF, please contact the clinic or the client for the PDF version.
Rainbow Mental Health, PLLC

Email: admin@rainbowmentalhealth.co www.rainbowmentalhealth.co P: (224) 263-4671 F: (224)346-6471
This questionnaire was adapted from the Massachusetts Medical Center Adult ADHD Clinic Structured Protocol "Interview for Adult ADHD".
Should be Empty:

Adult ADHD Parent Questionnaire

Additional Information Regarding ADHD Symptoms:

Developmental History:

School History

Family History

Thank you again for your time.

Rainbow Mental Health, PLLC